JOURNAL CLUB ARTICLE

Aluisio AR, Barry MA, Martin KD, Mbanjumucyo G, Mutabazi ZA, Karim N, et al. Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study. Afr J Emerg Med. 2019; 9: 14-20.

KEY QUESTION

What is the impact of formalized Emergency Medicine training on patients treated at the University Teaching Hospital-Kigali (UTH-K) Emergency Centre?

BACKGROUND

Formal emergency medicine training in the majority of low and middle-income countries (LMICs) is still in early stages of development. At the same time Emergency Centre (EC) mortality in LMICs is high, with a meta-analysis demonstrating a median mortality prevalence of 1.8%.[1] Although there are multi-factorial reasons for this high mortality rate, the authors state a lack of a robust formally trained emergency medicine workforce is one of the proposed problems.[1,2] Additionally, multiple advisory boards, including the World Health Organization, agree that improving the strength and capabilities of LMICs emergency care systems is crucial as health burdens are projected to increase disproportionately in these countries.[3,4,5] As a response, the development of systems to improve emergency care have been undertaken by LMICs, including the implementation of triage systems, focused courses on treating injuries, and the initiation of formal emergency medicine training programs for physicians.[6, 7] According to the authors, “Rwanda is a LMIC in sub-Saharan Africa that has radically transformed its healthcare system through the creation of national insurance,[8] community health expansion,[9] and HIV treatment.”[10] In addition to these major initiatives, the nation’s first emergency medicine training program was developed at UTH-K, thus providing the authors an opportunity to study the effects of implementing formalized EM training in a LMIC.

STUDY DESIGN AND METHODOLOGY

The study utilized a retrospective interrupted time-series that was carried out at the UTH-K in Kigali, Rwanda. The UTH-K is a tertiary-care institution with approximately 40 EC and 500 inpatient beds, and one of Rwanda’s national public referral health centers. The authors state “The interrupted time-series approach was chosen as it is a validated method to evaluate healthcare improvement strategies while controlling for secular trends,” referencing Penfold et al (2013) and Macbride-Stewart et al (2017). The study compared two time periods, pre-EM training implementation including November 2012 to October 2013 and post-EM training implementation August 2015 to July 2016. Cases considered for inclusion were identified from the hospital’s electronic medical records of all EC visits during the time periods studied. The coded cases were then randomly sampled to obtain a sufficient number of case records, which the authors considered to be 135 to 165 records per month of study. The primary predictor variable studied was the period of care defined as the reference of pre-EM training (November 2012 to October 2013) or comparator of post-EM training and systems implementation.

INTERVENTION

During the pre-EM training study period Emergency Care at the UTH-K EC was provided exclusively by twelve general practice physicians (GPs) 24-hours per day. The intervention evaluated by the authors was the establishment of formalized EM training and associated improvements to EC systems. This included an EM post-graduate diploma program initiated in October 2013, which was later transitioned into a comprehensive four-year EM residency-training program in August 2015. During the post-EM training period, EC care was delivered by seven independently practicing GPs and fourteen EM residents with faculty oversight. Shifts for each provider type were staffed only by the specific type of provider (i.e. GP or EM resident providers). Additionally, the authors state that after the development of the EM training program, no significant changes were made in the physical structure of the EC or the availability of equipment/supplies, except for the phasing in of point-of-care ultrasound as residents completed ultrasound training.

INCLUSION CRITERIA

Inclusion eligibility was based on all patients presenting to the EC within the two time periods studied; pre-EM training implementation including November 2012 to October 2013 and post-EM training implementation August 2015 to July 2016.

EXCLUSION CRITERIA

Cases without identifiable medical records or lacking EC record documentation for the encounter of interest were excluded.

SAMPLE SIZE

Among 43,213 EC cases during the study periods, 10,424 were randomly selected and screened. Of these, a total of 3,609 cases met inclusion and were analyzed. There were 1952 pre-EM training cases and 1657 post-EM training cases sampled (Fig. 1). Between both time periods there were no significant differences in cases based on age, gender, case type, or prior medical history.

RESULTS

The authors found the intervention of formalized EM training resulted in a 43% reduction in hospital mortality likelihood (aOR=0.57, 95% CI 0.36–0.94; p=0.016). This was calculated based on the pre-training overall hospital mortality of 12.2% (95% CI 10.9–13.8%), while the post-EM training overall hospital mortality was 8.2% (95% CI 6.9–9.6%). Of note the pre-EM training emergency care mortality was 6.3% (95% CI 5.3–7.5%), while post-training EC mortality was 1.2% (95% CI 0.7–1.8%). Inpatient mortality was not significantly different during the pre-EM training period and post-EM training periods (11.6% versus 11.2%) (Table 1).

DISCUSSION

The results demonstrate an association between decreased hospital mortality at UTH-K and the implementation of a formalized emergency medicine training program. This study provided the first concrete data on such an association and should be used to encourage other countries and health centers to allocate funding and resources to establish their own formalized EM training programs. Notably, the decrease in EC mortality was the driving force behind the hospital wide mortality reduction as explained above and further supports the idea that the EM training intervention was responsible for the decrease, despite the study design being unable to demonstrate causality. The authors also note that a meta-analysis found that in Africa the median EC mortality was 4.8%, a number 100 times greater than EC mortality in the United States. If the results found in this study can be replicated at other hospitals, even at a fraction of what occurred during this study, there would be substantial improvements in patient centered outcomes in emergency care in LMICs.

LIMITATIONS

The authors recognize that along with the establishment of EM specific training there was the addition of formalized triage, team-based resuscitation and the designation of higher acuity areas in the EC which may have contributed to the decreased mortality.[11,12] Additionally, there is an inherent limitation to a retrospective study design as eligible cases will be missed due to insufficient data  The authors also note that this study took place at a single large academic hospital with additional external resources which may limit the generalizability of the results. Although the mortality reduction was statistically significant it is difficult to separate the reduction in mortality related to the specific change in clinical skills by providers who have completed formalized emergency medicine training, as opposed to the EC system improvements that are associated with formalized training.  Another limitation is the lack of comparison between the outcomes of patients treated by GPs versus EM physicians during the post-EM training study period.  As both GPs and EM physicians were seeing patients during this time period a comparison may help determine if the decreased mortality is driven by specific clinical skills of EM trained physicians or the system wide improvements that coincide with the development of a formalized EM training program.

FUTURE DIRECTIONS

As emergency medicine grows as a specialty in LMICs there will be opportunities to study the effects of both improvement in emergency care systems and physicians’ improved ability to care for emergent patients due to formalized EM training. Prospective randomized control studies conducted in LMICs would enhance the data regarding patient centered outcomes associated with the implementation of EM training. Understanding what aspects of system wide improvement such as organized triage, pre-hospital care training, use of trauma algorithms, and introduction of ultrasound lead to the most cost-effective improved patient outcomes will ultimately allow for the most widespread improvement in emergency care.

FACULTY REVIEWER

Dr. Taneisha Wilson

REFERENCES

1. Obermeyer Z, Abujaber S, Makar M, et al. Emergency care in 59 low and middle income countries: a systematic review. Bull World Health Organ. 2015; 93: 577–586G.

2. Baelani I, Jochberger S, Laimer T, et al. Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self-reported, continent-wide survey of anaesthesia providers. Crit Care. 2011; 15: R10.

3. Smith J, Haile-Mariam T. Priorities in global emergency medicine development. Emerg Med Clin North Am. 2005; 23: 11–29.

4. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235

   causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the

   Global Burden of Disease Study 2010. Lancet. 2012; 380: 2095–2128.

5. Anderson PD, Suter RE, Mulligan T, et al. World Health Assembly Resolution 60.22

   and its importance as a health care policy tool for improving emergency care access

   and availability globally. Ann Emerg Med. 2012; 60(35–44): e33.

6. Pek JH, Lim SH, Ho HF, et al. Emergency medicine as a specialty in Asia. Acute Med

   Surg. 2016; 3: 65–73.

7. Molyneux E, Ahmad S, Robertson A. Improved triage and emergency care for

   children reduces inpatient mortality in a resource-constrained setting. Bull World

   Health Organ. 2006;84:314–9.

8. Ali J, Adam R, Butler AK, et al. Trauma outcome improves following the advanced

   EC, emergency centre; OR, odds ratio; aOR, adjusted odds ratio; CI, confidence

   interval. Afr J Emerg Med. 2019; 9:14–20.

9. Ali J, Adam R, Chang H, et al. Trauma outcome improves following the advanced trauma life support program in a developing country. J Trauma. 1993; 34: 890–8.

10. Karara G, Verbeke F, Nyssen M. The role of hospital information systems in universal

    health coverage monitoring in Rwanda. Stud Health Technol Inform. 2015; 216: 193–7.

11. Condo J, Mugeni C, Naughton B, et al. Rwanda's evolving community health worker

    system: a qualitative assessment of client and provider perspectives. Hum Resour

    Health. 2014; 12: 71.

12. Nsanzimana S, Prabhu K, McDermott H, et al. Improving health outcomes through

    concurrent HIV program scale-up and health system development in Rwanda: 20

    years of experience. BMC Med. 2015; 13: 216.

13. Mbanjumucyo G, DeVos E, Pulfrey S, Epino HM. State of emergency medicine in

    Rwanda 2015: an innovative trainee and trainer model. Int J Emerg Med. 2015; 8: 20.

14. Mbanjumucyo G, Henwood PC. Focused assessment with sonography for HIV-associated

    tuberculosis (FASH) case series from a Rwandan district hospital. Afr J

    Emerg Med. 2016; 6(4): 198–201.